diagnostics
Article
Relationship between Abdominal Volume Index and
Body Adiposity Index and Scales of Insulin Resistance and
Metabolic Syndrome
José Ignacio Ramírez-Manent 1,2,3,4 , Ángel Arturo López-González 1, * , Pilar Tomás-Gil 1 ,
Pere Riutord-Sbert 1 , Lucía Garrido-Sepulveda 5 and María Teofila Vicente-Herrero 1
Citation: Ramírez-Manent, J.I.;
López-González, Á.A.; Tomás-Gil, P.;
Riutord-Sbert, P.; Garrido-Sepulveda,
L.; Vicente-Herrero, M.T.
Relationship between Abdominal
Volume Index and Body Adiposity
Index and Scales of Insulin
Resistance and Metabolic Syndrome.
Diagnostics 2023, 13, 3356. https://
doi.org/10.3390/
diagnostics13213356
Academic Editor: Rosaria Vincenza
Giglio
Received: 20 September 2023
Revised: 22 October 2023
Accepted: 23 October 2023
Published: 31 October 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Diagnostics 2023, 13, 3356. https://doi.org/10.3390/diagnostics13213356
1 ADEMA-Health Group, IUNICS University of Balearic Islands, 07009 Palma, Spain;
joseignacio.ramirez@ibsalut.es (J.I.R.-M.); secretaria@eua.edu.es (P.T.-G.); pereriutord@gmail.com (P.R.-S.);
correoteo@gmail.com (M.T.V.-H.)
2 Faculty of Medicine, University of the Balearic Islands, 07009 Palma, Spain
3 Institut d’Investigació Sanitària de les Illes Balears (IDISBA), Balearic Islands Health Research Institute
Foundation, 07004 Palma, Spain
4 General Practitioner Department, Balearic Islands Health Service, 07003 Palma, Spain
5 Home Hospitalization Unit, Arnau de Vilanova Hospital, 46015 Valencia, Spain; luciags85@gmail.com
* Correspondence: angarturo@gmail.com; Tel.: +34-687548105
Abstract: Introduction, objectives: Obesity is a global health problem with a great negative impact
on health. Among the pathologies caused by obesity are insulin resistance and metabolic syndrome,
which constitute an increasingly common health problem in both developed and developing countries.
The aim of this study was to examine the relationship between two scales that assess obesity—
based on hip circumference—and metabolic syndrome (MetS) and insulin resistance risk scales
as predictors of these alterations. Materials, methods: A descriptive, cross-sectional study was
carried out on 193,462 workers from different Spanish regions and work groups between January
2019 and September 2021. Abdominal volume index (AVI) and body adiposity index (BAI) were
evaluated to assess obesity and its association with insulin resistance using three risk scales (TyG
index, Triglycerides/HDL, and METS-IR), while their association with metabolic syndrome was
determined using the NCEP ATP III, IDF, and JIS models. Results: The results of the ROC curves to
determine the predictive value of BAI and AVI in relation to the three criteria evaluated to calculate
MetS in all instances presented a higher area under the curve (AUC) for AVI. The high values of
AVI stand out for predicting MetS when applying the IDF criteria. The cut-off point in women was
13.70 with a Youden index of 0.802, whereas in men, the cut-off point was set at 17.59 with a Youden
index of 0.672. Regarding the relationship of BAI and AVI with insulin resistance risk scales for
both sexes, the AUC only revealed high values when using the METS-IR formula for both AVI and
BAI. The AVI cut-off points to predict high values of insulin resistance risk scales in women were
established at 13.12 with a Youden index of 0.722. In men, the cut-off point was 17.59, with a Youden
index of 0.626. The BAI cut-off points in women were set at 33.88 with a Youden index of 0.748. In
men, the cut-off point was 27.91, with a Youden index of 0.598. Conclusions: AVI demonstrated its
value as a predictor of metabolic syndrome while exclusively applying the IDF criteria. AVI and BAI
demonstrated their value as predictors of high values of insulin resistance risk scales only in the case
of METS-IR. This predictive value is also higher in women.
Keywords: metabolic syndrome; insulin resistance; ROC curve; obesity
1. Introduction
Obesity can be defined as a state in which there is an abnormal or excessive accumu-
lation of fat within the body in relation to the values expected according to height, age,
and sex. This accumulation of fat has a negative impact on health, as it is associated with
metabolic syndrome and insulin resistance [1,2].
https://www.mdpi.com/journal/diagnostics
Diagnostics 2023, 13, 3356 2 of 14

Although there are numerous ways to measure this excess and its distribution in the
body, it is essential to use a simple technique that enables the diagnosis and classification
of the problem for epidemiological purposes regardless of race and country [3,4], whether
to compare populations, to identify individuals at risk of morbidity and mortality [5–7], or
to establish priorities for individual and community intervention [8–10].
Even though populations of various races, ethnicities, and environmental backgrounds
are very different in terms of the risk associated with the accumulation of a specific amount
of fat or its distribution, it is crucial to establish a consensus on the definition and classifica-
tion of obesity [11,12]. Determination of this unification is currently based on body mass
index (BMI) [13,14] and waist circumference [15,16]. However, there are other scales that
evaluate obesity that are based on hip circumference—such as the abdominal volume index
(AVI) [17,18]—which better assesses the accumulation of fat in the abdominal area, thereby
providing a better prediction for the development of metabolic syndrome (MetS) and
cardiovascular risk (CVR). There is also the body adiposity index (BAI), although this does
not offer better results than BMI to evaluate metabolic and cardiovascular risk, depending
on the origin of the population and race studied, according to published literature [19,20].
This constitutes a challenge for clinical research that must advance on this topic.
Insulin resistance is an increasingly common health problem today [21], and it is rising
in both developed and developing countries [22,23]. It appears when the body is not able
to respond normally to the insulin produced by the pancreas, which makes it difficult for
glucose to enter the cells and be used by them. Its appearance is favored by a high BMI,
inflammation, and oxidative stress caused by obesity, diet, age, physical inactivity, and
paternal history [24].
Under normal conditions, insulin is involved in the metabolism of carbohydrates,
lipids, and proteins and in anabolic function. The decrease or complete loss of the sensitivity
of the liver, muscle, or fatty tissue to the action of insulin is what constitutes insulin
resistance. [25].
The loss or alteration of the essential action of insulin stimulates an increase in insulin
production by the beta cells of the pancreatic islets, which causes an elevated level of
insulin in the blood, as well as raised glucose levels. This hyperinsulinemia causes a greater
production of fatty acids, which further hinder the action of insulin [26] and cause early
atherosclerosis, atherogenic dyslipidemia, and arterial hypertension. This excess of fatty
acids accumulates in the abdominal adipose tissue—known as central obesity—in muscles
and also in the liver—known as hepatic steatosis [27] or fatty liver.
The fundamental component that facilitates insulin resistance is excess nutrients,
which causes ectopic lipid storage that leads to insulin resistance at the muscle and liver
level and the consequent increase in adipose tissue [28–31]. This increase in adipose tissue
may not be pathological as it occurs in adolescence, aging, or even pregnancy, but it is
closely related to MetS (hypertension, dyslipidemia, obesity, and diabetes), although they
are not synonymous [32–34].
Based on the above, the objective of this study was to examine the relationship be-
tween two scales that assess obesity—based on hip circumference—and MetS and insulin
resistance risk scales as predictors of these alterations.

2. Methods
A descriptive, cross-sectional study was carried out on 193,462 workers (116,407 men
and 77,055 women) from different Spanish regions and work groups, especially hospitality,
construction, commerce, health, public administration, transport, education, industry, and
cleaning.
The workers were selected from those who attended the medical health examinations
carried out in the different participating companies in the period between January 2019
and September 2021.
The following were established as inclusion criteria (Figure 1):
- Being between 18 and 67 years old.
 The workers were selected from those who attended the medical health examina-
tions carried out in the different participating companies in the period between January
2019 and September 2021.
Diagnostics 2023, 13, 3356 The following were established as inclusion criteria (Figure 1): 3 of 14

- Being between 18 and 67 years old.

- Belonging to one of the companies participating in the study.
-- Belonging
Not to alcohol
drinking one of the companies participating in the study.
regularly.
-- Not drinking
Agreeing alcohol regularly.
to participate in the study and granting the use of the data for epidemio-
- Agreeing
logical to participate in the study and granting the use of the data for epidemiologi-
purposes.
cal purposes.

Figure 1.
Figure Flowchart
1.Flow chartofofparticipants.
participants.

Health professionals
Health professionals from
from each
each participating
participating company
company determined
determined the the anthropomet-
anthropo-
ric, analytical, and clinical variables necessary to calculate the
metric, analytical, and clinical variables necessary to calculate the scales used scales used in this study.
in this
Measurement techniques were standardized to reduce potential
study. Measurement techniques were standardized to reduce potential biases during thebiases during the process
of obtaining
process variables.
of obtaining variables.
A SECA
A SECA modelmodelheight
heightand
andweight
weightscale
scalewas was used
used toto measure
measure thethe height
height andand weight
weight
of the
of the person
personwhile
whiletheytheywere
wereininan anerect
erectposition
position with
with their
their abdomen
abdomen relaxed,
relaxed, according
according
to the international standards for ISAK anthropometric evaluation
to the international standards for ISAK anthropometric evaluation [35]. Abdominal waist [35]. Abdominal waist
circumference was measured in this same position, with a measuring
circumference was measured in this same position, with a measuring tape placed parallel tape placed parallel
to the
to the floor
floor at
at the
themidpoint
midpointbetween
betweenthe thelast
lastribriband
and the
the iliac
iliac crest
crest [36].
[36]. To To measure
measure hiphip
circumference, the subject had to be standing and have their arms
circumference, the subject had to be standing and have their arms crossed over their crossed over their chest.
The measuring tape was placed on the most prominent part of the
chest. The measuring tape was placed on the most prominent part of the buttocks, mak- buttocks, making sure
that it was completely horizontal (at the same height) at the back
ing sure that it was completely horizontal (at the same height) at the back and front. and front.
Body mass index (BMI) was obtained by dividing weight (in kg) by height (in
meters) squared.
A calibrated OMRON M3 automatic sphygmomanometer was used to measure blood
pressure in the supine position after 10 min of rest (cuff size adjusted to arm circumference).
The average of the three measurements carried out at one-minute intervals was calculated.
Enzymatic methods were used to measure glycemia and triglycerides, as well as
precipitation methods for HDL cholesterol after fasting for at least twelve hours. The
measuring unit used was mg/dL. LDL was obtained indirectly using the Friedewald
Diagnostics 2023, 13, 3356 4 of 14

formula. Blood samples were obtained by peripheral venipuncture and sent to reference
laboratories, where they were processed between 48 and 72 h.
To calculate Insulin Resistance, three risk scales were used:
- Triglycerides/HDL. The cut-off point for insulin resistance was set at 2.4. [37]
- Triglyceride glucose index (TyG index) [38] was calculated from the following formula:

TyG index = Ln(triglycerides × glycemia/2)

The cut-off point for the TyG index has been established at 8.8 in men and 8.7 in
women [39].
Metabolic Score for Insulin Resistance (METS-IR) [40] was obtained using the formula:

METS-IR = Ln(2 × glycemia + triglycerides) × BMI/Ln HDL-c

MetS was determined using three models:

(a) NCEP ATP III [41] considers metabolic syndrome when there are three or more of the
following events: blood pressure greater than 130/85 mmHg; triglycerides greater
than 150 mg/dL or specific treatment for this lipid disorder; Low HDL and blood
glucose less than 100 mg/dl or specific treatment for this glycemic disorder.
(b) The International Diabetes Federation (IDF) [42] requires, in addition to two of the
factors mentioned above for ATP III (triglycerides, HDL, blood pressure, and blood
glucose), a waist circumference greater than 80 cm in women and 94 cm in men.
(c) The JIS model [43] establishes criteria that are similar to those of NCEP ATPIII but
with abdominal waist cut-off points similar to the IDF.
As obesity scales based on hip circumference, the following were calculated:
- Abdominal volume index (AVI) [44] determined using the formula

AVI = [2 cm (waist)2 + 0.7 cm (waist-hip)2 ]/1000

- Body adiposity index (BAI) [45] which was obtained by applying the formula
√
BAI = (100 × hip circumference)/(height × height) − 18
A person was considered a smoker if they had consumed at least one cigarette in the
previous month or if they had stopped smoking less than a year before.
To evaluate dietary and physical activity habits, the Mediterranean diet adherence
questionnaire and the International Physical Activity Questionnaire (IPAQ) were used,
both self-administered.
The “Mediterranean Diet Adherence Questionnaire” is based on the PREDIMED study
(MeDiet-Predimed), which consists of 14 questions scored with 0 or 1 point each and is
used to evaluate adherence to the Mediterranean diet. Scores less than nine indicate poor
adherence to the diet, while scores of nine or more indicate excellent adherence [46].
The International Physical Activity Questionnaire (IPAQ) [47] has demonstrated its
usefulness in evaluating the physical activity that a person has carried out in the last
seven days. It is a self-administered questionnaire of seven questions, which allows easy
assessment of the frequency, duration, and intensity of physical activity carried out by
classifying it into three levels: vigorous, moderate, and low physical activity.
Three categories of social classes were created based on the profession and the proposal
of the group of social determinants of the Spanish Society of Epidemiology [48], which
establishes three categories: Class I includes directors and managers, athletes and artists,
university professionals, and qualified self-employed workers. Class II includes intermedi-
ate occupations and unskilled self-employed workers. Class III includes unskilled workers.

Statistical Analysis
The mean and standard deviation of quantitative variables were calculated using
Student’s t test. The chi-square test was used for qualitative variables. The usefulness
Diagnostics 2023, 13, 3356 5 of 14

of the BAI and AVI scales for predicting insulin resistance and metabolic syndrome was
calculated by applying ROC curves, obtaining the area under the curve (AUC), and the
cut-off points with their sensitivity, specificity, and Youden index. The SPSS 28.0 program
was used to perform the statistical analysis, and a statistical significance level of p < 0.05
was accepted.

3. Results
Men made up 60.2% of the sample. The average age of the participants was slightly
over 39 years (39.2 years in women and 39.8 years in men), with the majority group being
between 30 and 49 years of age. The majority belonged to the most disadvantaged social
class (class III) and had only a primary education. The average values of blood pressure,
basal blood glucose, cholesterol, and its fractions, and triglycerides were within normal
limits, although values were, on the whole, higher in men. Women, on the other hand, had
a greater adherence to the Mediterranean diet and did more physical activity on a regular
basis. A high percentage of the studied population were smokers (37.1% in men and 33.0%
in women). The complete data can be consulted in Table 1.

Table 1. Characteristics of the population.

Men n = 116,407 Women n = 77,055

Mean (SD) Mean (SD) p-Value
Age (years) 39.8 (10.3) 39.2 (10.2) <0.001
Height (cm) 173.9 (7.0) 161.2 (6.6) <0.001
Weight (kg) 81.1 (13.9) 65.3 (13.2) <0.001
Waist circumference (cm) 87.7 (9.1) 73.9 (7.9) <0.001
Hip circumference (cm) 100.0 (8.4) 97.2 (8.9) <0.001
Systolic blood pressure (mmHg) 124.4 (15.1) 114.4 (14.8) <0.001
Diastolic blood pressure (mmHg) 75.4 (10.6) 69.7 (10.3) <0.001
Total cholesterol (mg/dL) 195.9 (38.9) 193.6 (36.4) <0.001
HDL-c (mg/dL) 51.0 (7.0) 53.7 (7.6) <0.001
LDL-c (mg/dL) 120.5 (37.6) 122.3 (37.0) <0.001
Triglycerides (mg/dL) 123.8 (88.0) 88.1 (46.2) <0.001
Glycemia (mg/dL) 88.1 (12.9) 84.1 (11.5) <0.001
% % p-Value
20–29 years 17.9 19.5 <0.001
30–39 years 33.1 33.3
40–49 years 29.7 29.4
50–59 years 16.3 15.3
60–69 years 3.0 2.5
Primary school 61.2 51.8 <0.001
Secondary school 34.0 40.7
University 4.8 7.5
Social class I 5.3 7.2 <0.001
Social class II 17.4 33.2
Social class III 77.3 59.8
No physical activity 54.5 47.8 <0.001
Yes physical activity 45.5 52.2
Non-healthy food 59.0 48.6 <0.001
Healthy food 41.0 51.4
Non-smokers 62.9 67.0 <0.001
Smokers 37.1 33.0
HDL-c High-density lipoprotein cholesterol. LDL-c Low-density lipoprotein cholesterol.

Figure 2 and Table 2 present the results of the ROC curves to determine the predictive
value of BMI (blue line), waist circumference (red line), BAI (purple line), and AVI (blue
line) in relation to the three criteria evaluated to determine the MetS. It is observed that the
areas under the curve are always higher for AVI. These values are practically the same for
 Smokers 37.1 33.0
HDL-c High-density lipoprotein cholesterol. LDL-c Low-density lipoprotein cholesterol.

Diagnostics 2023, 13, 3356
Figure 2 and Table 2 present the results of the ROC curves to determine the predic-
tive value of BMI (blue line), waist circumference (red line), BAI (purple line), and6 of AVI
14
(blue line) in relation to the three criteria evaluated to determine the MetS. It is observed
that the areas under the curve are always higher for AVI. These values are practically the
same for AVI compared to BMI and waist circumference. Additionally, they are very
AVI compared to BMI and waist circumference. Additionally, they are very similar to those
similar to those obtained with the BAI. Particularly noteworthy are the high AVI values
obtained with the BAI. Particularly noteworthy are the high AVI values to predict MetS by
toapplying
predict MetS
the IDFbycriteria,
applying the IDF in
especially criteria,
women. especially in women.

ROCcurves
Figure2.2.ROC
Figure curvesto
toassess
assessthe
the usefulness
usefulness of
of BAI
BAI and
and AVI
AVI for
for predicting
predicting metabolic
metabolicsyndrome
syndrome
bysex.
by sex.

Areasunder
Table2.2.Areas
Table under the
the BAI
BAI and
and AVI
AVI curve for predicting
predicting metabolic
metabolic syndrome
syndrome with
withthe
thedifferent
different
criteria
criteriaby
bysex.
sex.

AVI WomenAVI Women BAI Women

BAI Women BMI Women
BMI Women Waist
Waist Women
Women
AUC (95% CI)
AUC (95% CI) AUC (95% CI) CI)
AUC (95% AUC (95%
AUC (95% CI)
CI) AUC (95%
AUC (95% CI)CI)
MS ATPIII 0.829 (0.820–0.838) 0.757 (0.745–0.766) 0.825 (0.818–0.833) 0.824 (0.815–0.833)
MS ATPIII 0.829 (0.820–0.838) 0.757 (0.745–0.766) 0.825 (0.818–0.833) 0.824 (0.815–0.833)
MS IDF
MS IDF 0.961 (0.959–0.963)
0.961 (0.959–0.963) 0.781 (0.773–0.789)
0.781 (0.773–0.789) 0.880 (0.875–0.885)
0.880 (0.875–0.885) 0.960
0.960(0.959–0.962)
(0.959–0.962)
MS JISMS JIS 0.866 (0.860–0.872)
0.866 (0.860–0.872) 0.759 (0.752–0.767)
0.759 (0.752–0.767) 0.837 (0.831–0.843)
0.837 (0.831–0.843) 0.862
0.862(0.856–0.868)
(0.856–0.868)
AVI Men AVI Men BAI MenBAI Men BMI Men
BMI Men Waist Men
Waist Men
MS ATPIII 0.844 (0.839–0.849) 0.697 (0.692–0.702) 0.775 (0.771–0.780) 0.843 (0.838–0.848)
MS IDF 0.929 (0.927–0.930) 0.711 (0.707–0.716) 0.822 (0.819–0.825) 0.929 (0.927–0.931)
MS JIS 0.864 (0.860–0.868) 0.705 (0.701–0.710) 0.792 (0.788–0.795) 0.864 (0.860–0.867)

Table 3 details the AVI cut-off points to predict MetS according to the three models
used, separated by sex. In the case of the IDF in women, a cut-off point was established at
13.70 with a sensitivity of 90.2, specificity of 90.0, and Youden index of 0.802, whereas in
men, the cut-off point was established at 17.59 with a sensitivity of 83.6, specificity of 83.6,
and Youden index of 0.672. Likewise, we found that the Youden index for AVI presents
very similar results in the three models used, both in men and women, to those obtained
with the BMI and waist circumference.
Figure 3 and Table 4 present the results of the ROC curves to determine the predictive
value of BMI (blue line), waist circumference (red line), BAI (purple line), and AVI (blue
line) with respect to the high values of the insulin resistance risk scales. In this case, the
areas under the curve only present high values for both sexes when using the METS-IR
formula for both AVI and BAI, with a very good result in women on both scales. This also
coincides with the results obtained for BMI and waist circumference.
 Table 3. Cut-off points with their sensitivity, specificity, and Youden index of BAI and AVI for
predicting metabolic syndrome with the different criteria by sex.

AVI Women BAI Women BMI Women Waist Women

Diagnostics 2023,Cutoff-Sens-Specif-Youde
13, 3356 Cutoff-Sens-Specif-Youd Cutoff-Sens-Specif-Youd Cutoff-Sens-Specif-You 7 of 14
n en en den
MS ATPIII 12.34–73.9–73.8–0.477 31.62–69.5–69.3–0.388 27.25–75.8–74.7–0.505 77.0–74.1–71.5–0.457
MS IDF 13.70–90.2–90.0–0.802 31.62–69.8–69.7–0.395
Table 3. Cut-off 27.95–79.2–79.1–0.583
points with their sensitivity, 82.0–90.0–89.9–0.799
specificity, and Youden index of BAI and AVI for
MS JIS 12.72–81.6–81.2–0.628 31.46–68.8–68.7–0.375
predicting metabolic 27.25–76.6–75.9–0.529
syndrome with the different criteria by sex. 78.50–81.0–81.0–0.620
AVI Men BAI Men BMI Women Waist Women
AVI Women BAI Women BMI Women Waist Women
MS ATPIII 16.07–76.7–76.7–0.534 26.42–64.2–64.1–0.283 27.95–71.1–70.8–0.419 91.0–78.8–72.8–0.516
MS IDF Cutoff-Sens-Specif-
17.59–83.6–83.6–0.672 Cutoff-Sens-Specif-
26.42–65.2–65.1–0.303 Cutoff-Sens-Specif-
28.0–75.1–72.5–0.476 Cutoff-Sens-Specif-
93.0–85.6–82.7–0.683
Youden Youden Youden Youden
MS JIS 17.32–82.0–82.0–0.640 26.36–64.9–64.8–0.287 27.95–72.1–71.4–0.435 93.0–82.3–81.8–0.641
MS ATPIII 12.34–73.9–73.8–0.477 31.62–69.5–69.3–0.388 27.25–75.8–74.7–0.505 77.0–74.1–71.5–0.457
MS IDF 13.70–90.2–90.0–0.802 31.62–69.8–69.7–0.395 27.95–79.2–79.1–0.583 82.0–90.0–89.9–0.799
Figure 3 and Table 4 present the results of the ROC curves to determine the predic-
MS JIS 12.72–81.6–81.2–0.628 31.46–68.8–68.7–0.375 27.25–76.6–75.9–0.529 78.50–81.0–81.0–0.620
tive value of BMI (blue line), waist circumference (red line), BAI (purple line), and AVI
AVI Men BAI
(blue line) with respect toMen BMIinsulin
the high values of the Womenresistance riskWaist Women
scales. In this case,
MS ATPIII the areas under26.42–64.2–64.1–0.283
16.07–76.7–76.7–0.534 the curve only present27.95–71.1–70.8–0.419
high values for both sexes when using the
91.0–78.8–72.8–0.516
MS IDF 17.59–83.6–83.6–0.672 26.42–65.2–65.1–0.303 28.0–75.1–72.5–0.476 93.0–85.6–82.7–0.683
METS-IR formula for both AVI and BAI, with a very good result in women on both
MS JIS 17.32–82.0–82.0–0.640
scales. This also26.36–64.9–64.8–0.287
coincides with the results27.95–72.1–71.4–0.435 93.0–82.3–81.8–0.641
obtained for BMI and waist circumference.

Figure 3. ROC curves to assess the usefulness of BAI and AVI for predicting high-risk values of
insulin resistance scales by sex.

Table 4. Areas under the BAI and AVI curve for predicting high-risk values of insulin resistance
scales by sex.

AVI Women BAI Women BMI Women Waist Women

AUC (95% CI) AUC (95% CI) AUC (95% CI) AUC (95% CI)
TyG index 0.678 (0.671–0.684) 0.655 (0.649–0.661) 0.713 (0.707–0.718) 0.673 (0.66–0.679)
TG/HDL 0.637 (0.632–0.642) 0.632 (0.627–0.637) 0.680 (0.676–0.685) 0.632 (0.627–0.637)
METS-IR 0.936 (0.933–0.939) 0.951 (0.948–0.953) 0.993 (0.993–0.994) 0.919 (0.916–0.923)
AVI Men BAI Men BMI Men Waist Men
TyG index 0.689 (0.686–0.693) 0.629 (0.625–0.633) 0.683 (0.679–0.686) 0.689 (0.685–0.693)
TG/HDL 0.694 (0.691–0.698) 0.633 (0.629–0.636) 0.682 (0.679–0.686) 0.694 (0.690–0.698)
METS-IR 0.894 (0.891–0.897) 0.882 (0.878–0.885) 0.968 (0.967–0.970) 0.889 (0.886–0.892)

In Table 5, we see the cut-off points calculated for both scales. The AVI cut-off points for
predicting high values of the insulin resistance risk scales in women were set at 13.12 with
Diagnostics 2023, 13, 3356 8 of 14

a sensitivity of 86.2, a specificity of 86.0, and a Youden index of 0.722. In men, the cut-off
point was 17.59 with a sensitivity of 81.5, specificity of 81.1, and Youden index of 0.626.

Table 5. Cut-off points with their sensitivity, specificity, and Youden index of BAI and AVI for
predicting high-risk values of insulin resistance scales by sex.

AVI Women BAI Women BMI Women Waist Women

Cutoff-Sens-Specif- Cutoff-Sens-Specif- Cutoff-Sens-Specif- Cutoff-Sens-Specif-
Youden Youden Youden Youden
TyG index 11.64–61.8–61.6–0.234 30.42–61.1–61.0–0.221 25.65–66.6–66.3–0.329 75.0–61.8–61.1–0.229
TG/HDL 11.46–59.5–59.3–0.188 30.07–59.5–59.3–0.188 25.05–63.8–63.5–0.273 75.0–63.0–61.8–0.248
METS-IR 13.12–86.2–86.0–0.722 33.88–87.9–86.9–0.748 32.15–96.1–95.9–0.920 79.0–85.8–82.9–0.687
AVI Men BAI Men BMI Women Waist Women
TyG index 11.60–62.5–62.3–0.248 25.72–59.3–59.0–0.183 26.85–65.2–62.7–0.279 88.0–62.4–62.2–0.244
TG/HDL 15.64–62.5–62.4–0.249 25.75–59.7–59.2–0.189 26.85–65.5–62.2–0.277 88.0–62.8–61.8–0.246
METS-IR 17.59–81.5–81.1–0.626 27.91–79.9–79.9–0.598 30.45–89.9–89.9–0.798 93.0–81.6–79.9–0.615

The BAI cut-off points for predicting high values of the insulin resistance risk scales in
women were set at 33.88 with a sensitivity of 87.9, a specificity of 86.9, and a Youden index
of 0.748. In men, the cut-off point was 27.91 with a sensitivity of 79.9, specificity of 79.9,
and Youden index of 0.598. These results are also similar to those obtained for BMI and
waist circumference. Although in the case of BMI, they have a higher Youden index.

4. Discussion
In this large population sample, we studied 193,462 workers of both sexes between
18 and 69 years of age, all of them from different autonomous communities in Spain.
Although the sample is somewhat larger in men, 60% compared to women, 40%, we believe
that the large volume of the sample and having stratified it by sex offer valid results.
As this is a sample that comes from workers who attend company medical examina-
tions, we could be committing healthy worker bias since sick workers do not regularly
attend these [49]. However, in our study, we did not compare a pathology between healthy
and sick workers, but rather the relationship between two formulas to measure the amount
of body fat and insulin resistance and MetS. Neither was a pathology related to the job
or influenced by a substance to which workers are exposed evaluated. We consider that
workers belonging to multiple companies also constitute a representation of the general
population. Although people with MetS or insulin resistance are susceptible to suffering
from more pathologies [50], it is our belief that the large sample size and the particular
research question (relationship between formulas) override this bias as the study was not a
question of occupational epidemiology [51].
Another factor that can influence metabolic syndrome is aging since there are numer-
ous publications that demonstrate a change in metabolism with aging and, consequently,
an increase in metabolic syndrome with aging. However, the published literature refers to
the population over 60 years of age [52]. In our work, only 5.5% of the population (3.0%
of men and 2.5% of women) is 60 or older, so due to the enormous size of the sample, we
have considered that it will not influence the results.
In our study, AVI has a good predictive value for MetS in both men and women with
the three formulas used. However, the highest values occur when applying the IDF MetS
criteria. When applying the ATPIII and JIS MetS criteria, the AUC for AVI is greater than
0.8 in both cases, and this result occurs in both men and women, which can be interpreted as
a good test result for both sexes. In the case of the AUC corresponding to the IDF definition,
the results are greater than 0.9, also for both sexes, which implies a very good test result,
enabling us to affirm that there is a close relationship between AVI and the prediction of
MetS according to IDF criteria. If we also focus on women, the AUC can be seen to be 0.961,
which is very close to 0.97, which is accepted as an excellent result in the interpretation of
Diagnostics 2023, 13, 3356 9 of 14

results [53]. These values are practically the same as those obtained with BMI and waist
circumference both in the AUC and in the Youden index; the usefulness of these indexes,
as we have commented at the beginning of the article.
Regarding BAI, this also has a good predictive value in women since, for the three
formulas used, the AUC is greater than 0.75, which enables the test results to be interpreted
as good. However, with regard to the men in the study, none of the three formulas used to
assess the MetS have an acceptable predictive value with BAI since its results are evaluated
as a regular test. Therefore, they are not considered a recommended formula to predict
MetS in men. These results are lower than those obtained with BMI and waist circumference
in both the AUC and the Youden index, and therefore, it is not better than these indices to
evaluate metabolic and cardiovascular risk in our population.
When establishing the AVI and BAI cut-off points to predict MetS, we found that in
the three formulas used, the sensitivity and specificity are low in the case of BAI for both
sexes, with a Youden index ranging between 0.283 and 0.395, thus leading us to rule out
this formula as it could give many false results.
In the case of AVI, both the JIS and IDF formulas have good sensitivity and specificity
in both sexes. Thus, in women, the cut-off for IDF was established at 13.70 with a Youden
index of 0.802, and the cut-off for JIS at 12.72 with a Youden index of 0.628. In the case of
men, the best value was also obtained with the IDF formula with a cut-off of 17.59 and a
Youden index of 0.672. As in women, the JIS formula is also acceptable, in whom a cut-off
of 17.32 was established with a Youden index of 0.604.
To evaluate insulin resistance, three risk scales were used: TyG index, TG/HDL, and
METS-IR. We are aware that most studies recommend the use of HOMA-IR (Homeostasis
Model Assessment of Insulin Resistance) [54]; however, since we did not have the fasting
insulin values of the people in our sample, we opted for other validated methods, such as
the aforementioned risk scales that are also recommended due to their low cost [55–59].
The predictive value of AVI and BAI on insulin resistance risk scales only offers an
AUC greater than 0.75 with the METS-IR formula. These results are good in both men and
women, although again, it is in women where it is closer to unity, bordering on excellence.
However, when establishing the cut-off points, we found that although the AVI values
were still good, the cut-off point for women was 13.12 with a Youden index of 0.722, while
the cut-off point for men was 17.59 with a Youden of 0.626. In the case of BAI for men,
the Youden index was 0.598, with a sensitivity of 79.9 and a specificity of 79.9, which,
being around 80%, could be accepted as valid. When comparing these results with the
AUC and the Youden index for BMI and waist circumference, we find that the results
are practically identical, although somewhat higher in the case of AVI when applying the
METS-IR formula.
One study carried out by Feng et al. in a Chinese population in 2007 evaluated the
usefulness of different overweight and obesity scales to predict insulin resistance in 570 non-
diabetic people [60]. In this case, the authors, unlike our study, directly measured insulin
resistance using HOMA-IR. Statistical analyses showed that BAI had a lower AUC than
AVI in predicting insulin resistance. After applying the Spearman test, insulin resistance
was more strongly correlated with waist circumference and AVI in men and with BMI in
women, while BAI showed a low correlation for both sexes.
In a cross-sectional study carried out on 981 Spanish adolescents (456 boys and
525 girls) [61,62], the validity of AVI to predict MetS calculated according to eight dif-
ferent criteria was determined, revealing great variability in the results depending on the
criteria used. Analysis of the ROC curves showed that the AUC was greater than 0.80 in
both boys and girls, but only when the diagnosis of MetS was established according to the
IDF criteria. These data agree with those obtained in our study, although our population
is adults.
Another study carried out in the Chinese population, published in 2017, in which
the ability of different anthropometric indices to predict MetS in a population between
Diagnostics 2023, 13, 3356 10 of 14

40 and 65 years of age was evaluated, concluded that BMI and AVI are better than other
anthropometric indices to predict MetS in both sexes [63].
One study was carried out on 886 Colombian university students with an average age
of slightly over 21 years. After assessing the ability of three BAI adiposity indices to predict
MetS using the IDF criteria, the authors concluded that BAI was useful for predicting
MetS and established the cut-off point at 30.34 (AUC = 0.720–0.863) for women and 27.83
(AUC = 0.726–0.873) for men [64]. These findings differ from our results since the AUC of
BAI to predict MetS according to IDF criteria was less than 0.75, and in the case of women,
although the AUC was 0.781, the Youden index was 0.395, which indicates low sensitivity
and specificity.
In 2022, a cross-sectional study carried out on the Vietnamese population from June
2007 to July 2008 was published. Four thousand and seventy-one people between 25 and
74 years old were studied, using nine anthropometric indices to predict MetS. NCEP ATP
III and IDF criteria, with modified central obesity cut-off values for Asians, were used to
define MetS. All the parameters studied to define MetS were found to present higher AUC
values when the IDF criteria were used compared to NCEP ATP III. Among them, AVI
presented a high predictive value of MetS in both sexes when IDF criteria were used, with
a cut-off point of 16.2 (AUC = 0.99) in men and 12.8 (AUC = 0.97) in women [65]. These
results also agree with those of our study, although in our case, the AUC was somewhat
higher for women than for men.
Chen et al. carried out a study in a population of 4767 Uyghurs (an ethnic group
living in the northwestern regions of China) selected from the Cardiovascular Risk Survey
carried out between October 2007 and March 2010, with the objective of identifying the
best predictor of MetS in this population [66]. Several anthropometric parameters—BMI,
WHtR, TGs/HDL-C, and BAI—were included to predict MetS according to IDF criteria,
concluding that, in the Uyghur population, WHtR (AUC = 0.838) was the best predictor of
MetS in men, whereas in women it turned out to be the TG/HDL-C ratio (AUC = 0.815). In
the case of BAI, the AUC was 0.709 for men and 0.699 for women. These last results are
similar to those found in our work.
The same authors as the previous paper carried out another study in the Chinese adult
population, in this case, the Kazakh population (ethnicity from the mixture of primitive
Turkic and Mongolian tribes) [67], in which 4094 people were included, assessing the
predictive power of different anthropometric scales on MetS applying the IDF criteria. In
this population, they found that the best predictor of MetS for both sexes was WHtR, with
an AUC of 0.821 in men and 0.835 in women. In this case, the AUC for the TG/HDL-C index
was 0.792 in men and 0.778 in women. Similar to the previous study, and in agreement
again with our study, the AUC for BAI was 0.666 for men and 0.751 for women, which
confirms that there is no good association between BAI and its predictive value for MetS.

Strengths and Limitations

As a strength of the study, we would like to highlight the large sample size, which gives
enormous power to the results obtained. As the sample comes from different companies
with the largest number of workers in Spain, they constitute a representative sample of
the population.
As a main limitation, it is worth noting that insulin resistance was not determined
using an objective method but rather using risk scales. Another limitation of our study is
not knowing the people in our population with previous treatments for metabolic disorders
or macrovascular diseases.

5. Conclusions
Only AVI demonstrated its value as a predictor of metabolic syndrome and exclusively
applied IDF criteria. This predictive value is higher in women.
AVI and BAI demonstrated their value as predictors of high values of insulin resistance
risk scales only in the case of METS-IR. This predictive value is also higher in women.
Diagnostics 2023, 13, 3356 11 of 14

Author Contributions: Conceptualization, J.I.R.-M. and Á.A.L.-G.; Methodology, L.G.-S. and P.T.-G.;
Validation, P.T.-G. and M.T.V.-H.; Formal analysis, Á.A.L.-G.; Investigation, L.G.-S.; Data curation,
Á.A.L.-G. and P.R.-S.; Writing—original draft Á.A.L.-G. and J.I.R.-M.; Writing—review and editing,
M.T.V.-H. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study was approved by the Clinical Research Ethics
Committee of the Balearic Islands Health Area in November 2020, which was obtained with the
following indicator IB 4383/20. The research team was always committed to following the ethical
principles of health sciences research established at the national and international level (Declaration
of Helsinki), paying special attention to the anonymity of the participants and the confidentiality of
the data collected.
Informed Consent Statement: All patients signed written informed consent documents before
participating in the study. The identity of the participants will not be disclosed in any report of
this study. The researchers will not disseminate any information that could identify them. In any
event, the research team undertakes to strictly comply with Organic Law 3/2018 of December 5 on
the protection of personal data and guarantee of digital rights, guaranteeing all participants in this
study that they may exercise their rights of access, rectification, cancellation, and opposition of the
data collected.
Data Availability Statement: The study data are stored in a database that complies with all se-
curity measures at ADEMA-Escuela Universitaria. The Data Protection Delegate is Ángel Arturo
López González.
Conflicts of Interest: The authors declare no conflict of interest.

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